Multimedia manual of cardiothoracic surgery : MMCTS / European Association for Cardio-Thoracic Surgery最新文献

In minimally invasive direct coronary artery bypass surgery, the integrity of the internal mammary artery graft depends on the minimization of trauma during its harvesting. Moreover, bipolar cauterization of side branches has shown superiority in animal studies. This report highlights the use of bipolar micro forceps in robotic skeletonized internal mammary artery harvesting. Its application offers optimal tissue handling, safe cauterization, minimal thermal spread, and time-efficiency, as instrument exchange is minimized, significantly decreasing harvesting time.

The patient was positioned supine with the right chest slightly elevated. Following induction of general anaesthesia and intubation using an endotracheal tube, connection to the cardiopulmonary bypass was established via the groin vessels under the guidance of transoesophageal echocardiography. Additionally, a venous cannula was inserted through the right internal jugular vein to facilitate bicaval cannulation. The surgery was performed via a 5 cm right mini-thoracotomy at the fourth intercostal space. After soft tissue retraction and pericardial traction sutures, a 3D camera port (Aesculap EinsteinVision, Germany) and a Chitwood clamp for aortic cross-clamping were inserted through separate incisions. Antegrade cold blood cardioplegia was administered via a catheter in the ascending aorta. The surgery involved several steps. For the 1st step, transatrial approach to the mitral valve through Waterston's groove was used. After that transmitral approach to the interventricular septum and submitral structures of the left ventricle was performed. Next step was septal myectomy and secondary chordae resection to the mitral valve. Finally, the anterior mitral valve leaflet reattachment to the annulus was done.

The Berlin Heart EXCOR Adult biventricular assist device (BiVAD) is an approved option for mechanical circulatory support in patients experiencing end-stage biventricular heart failure. In this video tutorial we demonstrate a clinical case of BiVAD EXCOR implantation in an adult.

Robotic cardiac surgery continues to evolve, offering patients a less invasive alternative to traditional median sternotomy, even for complex procedures. This report presents a case of robotic totally endoscopic aortic valve replacement using a rapid deployment valve combined with mitral valve repair, demonstrating the feasibility and safety of this approach.

Re-operation following previous congenital heart repair can be challenging. We present a 38-year-old female with a history of partial atrioventricular septal defect repair in infancy who developed severe mitral regurgitation due to a cleft anterior mitral leaflet. Given her anatomy and prior sternotomy, we performed a redo minimally invasive endoscopic mitral valve repair via right anterolateral minithoracotomy access. We meticulously closed the cleft using precise suture placement to restore leaflet integrity and function and performed an annuloplasty to reinforce the annulus and optimize leaflet coaptation. The minimally invasive approach minimized surgical trauma, while endoscopic visualization allowed for a precise and effective repair. This case highlights the feasibility of this approach in patients with complex congenital heart disease, offering a viable alternative to sternotomy with potential benefits for both short- and long-term outcomes.

Robotic-assisted thoracic surgery has become an increasingly valuable technique for performing complex lung resections, offering high-definition visualization, refined instrument control and tremor-free precision. When compared to open thoracotomy, robotic approaches are linked to lower perioperative morbidity, shorter hospitalizations and quicker recovery times. Nonetheless, sublobar resections such as segmentectomy remain technically and anatomically challenging procedures, particularly in the presence of anatomical anomalies, as demonstrated in this case involving the right S3 segment. Combined three-dimensional reconstruction imaging enables detailed preoperative mapping of pulmonary anatomy, allowing surgeons to visualize bronchovascular structures with greater clarity and tailor dissection plans accordingly. Despite its proven benefits, the routine use of three-dimensional virtual imaging in thoracic surgery remains vastly underutilized and under-represented in the current literature. This video tutorial forms part of the Segmentectomies Made Easy atlas and presents a robotic right S3 segmentectomy for an incidental small pulmonary lesion. Preoperative three-dimensional reconstruction revealed a unique anatomical variation, which proved critical in guiding the dissection strategy. The tutorial offers a comprehensive, step-by-step overview of the operative process-from port configuration to anatomical isolation and resection-highlighting the value of three-dimensional imaging in improving surgical precision, intraoperative decision making and overall outcomes in robotic segmental lung surgery.

A 13-year-old boy born with hypoplastic left heart syndrome, who underwent all three stages of univentricular palliation and multiple interstage operations, developed failing Fontan circulation with protein-losing enteropathy and massive pleural and peritoneal effusions. In this video tutorial, surgical assessment and implanting an isolated subpulmonary ventricular assist device for support using the EXCOR Venous Cannula and a 30-cc EXCOR system are described. In addition, aspects of the surgical removal of "fenestration" devices are reported. Cardiopulmonary bypass is established in a central fashion, and the procedure is conducted under mild hypothermia and partially induced ventricular fibrillation. The superior vena cava and an 18-mm extracardiac Fontan conduit are completely divided. The fenestration devices are partially removed through the opening in the right pulmonary artery. The EXCOR venous inlet cannula is first anastomosed to a rim of the Fontan graft connected to the inferior vena cava. Then it is anastomosed to the superior vena cava by means of an interposition graft. The final anastomosis connects the outflow cannula to the superior part of the former Fontan conduit.

A 47-year-old female with dyspnoea, poor blood pressure control and a family history of aortic disease presented with chronic type IA aortic dissection (with a maximal aortic diameter of 50 mm at the ascending aorta level). Anatomically, the patient presented with involvement of the brachiocephalic trunk and the left renal artery originated from the false lumen. The aortic valve was trileaflet but demonstrated severe eccentric insufficiency. Due to this constellation of findings, urgent surgical repair was indicated. Cardiopulmonary bypass was established centrally by direct true lumen cannulation with Seldinger echo-guided technique and cross-clamping between the distal ascending aorta and the proximal aortic arch (zone 0) performed while cooling. A period of high-moderate hypothermic circulatory arrest (26°C core temperature) with bilateral selective antegrade cerebral perfusion was utilized to complete the distal reconstruction. To repair the morphologically normal trileaflet but severely regurgitant aortic valve prolapsing in the dissected aortic root a valve-sparing aortic root replacement (David procedure) was performed.

The definitive treatment for patients with combined aortic valve and root pathologies is the Bentall procedure. A prosthetic aortic valve or a composite valved conduit is traditionally implanted using interrupted sutures. The forgotten continuous suture technique is emerging as a practical alternative with the benefits of easier handling, better control of bleeding and shorter ischaemic times. We describe the case of a 19-year-old male patient with Marfan syndrome who presented with severe aortic regurgitation and a hugely dilated aortic root and ascending aorta. He underwent a modified Bentall procedure using an indigenous prosthetic valved conduit implanted using a continuous suture technique. The procedure was uneventful, achieved adequate haemostasis, and good conduit alignment without paravalvular leakage. The postoperative course and further follow-ups were uneventful.

Robotic-assisted thoracic surgery has seen a significant rise in recent years, particularly for complex lung cancer resections. Robotic surgery offers advantages such as three-dimensional visualization, improved tissue manipulation and precise instrument control. In conjunction with other minimally invasive techniques, robotic-assisted thoracic surgery is increasingly preferred over traditional open thoracotomy for lung cancer resections. This development has been suggested to reduce postoperative morbidity, shorten hospital stay and hasten postoperative recovery. Although pulmonary segmentectomy can present technical challenges, the use of three-dimensional reconstruction imaging allows for detailed preoperative visualization of the tumour and the adjacent bronchovascular structures. This enables more accurate and anatomically tailored resections. However, despite its potential, the discussions of the integration of virtual three-dimensional lung reconstruction into routine thoracic surgical practice remain limited in the current literature. We present a video atlas series of robotic-assisted segmentectomies guided by three-dimensional reconstruction imaging. This video tutorial includes a step-by-step guide for performing a right S1 segmentectomy for a patient presenting with a right upper lobe tumour.